Returning to Work for People Living with Long COVID: Overview of Support and Advice

The titles and abstracts of articles obtained from the online databases were reviewed and appraised for relevance. Two researchers from the team read each title/abstract independently and judged whether they were relevant to the research question. When there were disagreements between reviewers, the principal researcher (DPG) offered additional consultation until a consensus was reached. If relevance of a study was still unclear, then the full article was obtained. After identifying relevant abstracts and titles, two independent researchers assessed the corresponding full versions of the studies to determine which articles were relevant for inclusion in the full review. All team members used Covidence software (Melbourne, Australia) to organize data at all review stages.

Reviewers extracted relevant information from each article. This included the author list, year of publication, article title, geographic location of the study, type and brief description of the intervention, study population, study design and goals, methods used, outcome measures used, important results and any economic data recorded.

During this stage, we created an overview of all research located. Initially, we presented a basic numerical summary of the studies, including the extent, nature and distribution of the articles. We then summarized articles according to the types of tools described or evaluated, research methods used, populations studied, and study results/outcomes. Since the scoping review methodology was intended to summarize both the breadth and depth of the literature, we reported the number of articles for various interventions as well as descriptive information about the articles.

We attempted to map the diversity of studies observed to create an inventory of the various study designs and methods used. This procedure allowed us to draw conclusions about the nature of research in this area and provide recommendations for future studies. The various interventions identified in the articles were categorized according to level of intervention promise, and key concepts and terminology used in the articles were summarized. To collate, summarize, and report results for this scoping review, we conducted a descriptive characteristic summary and content analysis of intervention studies [19].

We categorized interventions as promising, somewhat promising, or not promising based on a previously published categorization method [22,23]. Interventions were considered promising when results demonstrated statistically significant RTW outcomes or ≥ 50% RTW success. We categorized interventions as somewhat promising when RTW outcomes ranged from 20% to < 50% RTW success. We categorized interventions as not promising when results demonstrated non-statistically significant RTW outcomes or < 20% RTW success. Studies that did not examine RTW rates specifically, but examined other aspects of work ability were rated as 'uncertain'.

The relevant studies highlighted several successful approaches to rehabilitation and treatment for managing Long COVID or RTW. These programs ranged from specialized, individualized, multiple-session rehabilitation to concentrated three-day rehabilitation programs and exploratory medical procedures.

Rehabilitation programs that showed promising results for RTW included respiratory therapy, muscular training, a mental health component, and educational interventions [6,24,25]. Three studies found that multidisciplinary, individualized treatment plans were recommended to address Long COVID symptoms like fatigue, autonomic dysfunction, and cognitive deficits, which impact workplace sustainability [6,25,30]. Altmann et al. (2023) found breathing exercises and respiratory treatments facilitated by physical therapists aided individuals in managing symptoms of shortness of breath and fatigue crucial for RTW [25]. In addition, they found monitoring oxygen levels during rehabilitation and daily activities helped pace and manage PEM, contributing to sustainable RTW [25]. It was found that RTW readiness from a physical perspective, due to the variability of symptoms experienced, was challenging and required input from multiple experts and specialists [6]. Garbsch et al. (2024) employed both traditional and non-traditional therapies in a multidisciplinary inpatient rehabilitation program combining active, cognitive, and passive therapies resulting in significant workability improvement at 6 months post-rehabilitation compared to admission, with no notable sex differences [30]. In addition to physical rehabilitation, relaxation treatment and psychological counselling, this intervention also included aqua fitness, inspiratory muscle training, nutrition education, heat therapy, and group exercise [30].

Three other studies with multidisciplinary Long COVID rehabilitation programs, employed more non-traditional methods [24,36,39]. Frisk et al. (2023) demonstrated that micro-choices (3-day concentrated program) can enhance physical activity and functioning beyond symptom monitoring alone [24]. By incorporating patient education, individualized exercise to break inflexible patterns, physical activity training, and brief mindfulness sessions, the intervention led to a significant reduction in sick leave [24]. Furthermore, Frisk et al. (2025) also found that the concentrated, micro-choice-based treatment for Long COVID led to sustained improvements in sick leave, fatigue, and functional status at the one-year follow-up [39]. Schmid et al. (2024) demonstrated a substantial and sustained increase in work capacity following a multimodal rehabilitation program [36]. The intervention consisted of a wide range of more non-traditional therapies, including nutrition therapy, hydrotherapy/thermotherapy, mind-body medicine, phytotherapy, naturopathy, and traditional exercise therapy, individualized to each patient's symptoms and rehabilitation goals [36].

Muller et al. (2023) showed that rehabilitation targeting physical and neuropsychological health for individuals with Long COVID can lead to specific symptom reduction but not overall global fatigue and thus was considered somewhat promising [35]. This study measured various aspects of each symptom across two-time points with multiple tests and outcome measures, which documented a decreased prevalence in all symptoms except for fatigue [35]. Muller et al. (2023) found that despite the significant self-reported health improvements in people living with Long COVID, especially healthcare workers, they continued to suffer from poor workability with 72% of participants still unable to RTW post-rehabilitation [35,38]. In the 1-year follow-up study by Muller et al. (2024), the median WAI total score indicated poor workability that worsened significantly over time [34]. Thus, rehabilitation programs that lacked individualized treatment or had too many outcome measures were less effective and did not improve workability [35,38].

Altmann et al. (2023) also found that psychological counselling and coping strategies, such as mindfulness, helped manage anxiety and depression stemming from uncertainty about recovery, grief over lost abilities, and symptoms of Long COVID itself [25]. Early education on symptom management, pacing, graded return to activity, and energy conservation were emphasized as key components of interventions to manage Long COVID and build capacity for RTW [6,31]. Garcia-Molina et al. (2022) found that cognitive rehabilitation was effective for RTW in addressing cognitive impairments such as memory loss, brain fog, and concentration difficulties [26]. Interventions like cognitive pacing, compensatory strategies, and memory exercises enhanced mental clarity and cognitive function, supporting RTW [26]. In addition, Garcia-Molina et al. (2022) found that symptom monitoring tools like daily diaries or trackers helped individuals identify symptom patterns, enabling targeted interventions and a smoother RTW transition [26]. Nerli et al. (2024), highlighted the significance of a brief outpatient rehabilitation intervention based on the Cognitive Activation Theory of Stress in supporting RTW for people living with Long COVID [28]. By addressing cognitive expectancies that influence symptom persistence, this intervention helped modify patients' stress response and improve their symptom management, leading to short-term and sustained RTW outcomes at the end of the program and six months follow-up.

Ongoing monitoring and individualized treatment plans at the workplace were considered promising, with graduated RTW processes recommended to accommodate the fluctuating nature of Long COVID symptoms [6,31]. According to Brehon et al. (2022) and Garcia-Molina et al. (2022), RTW planning with modified, gradual returns (including adjusted hours and duties) was essential to accommodate fluctuating and episodic Long COVID symptoms and led to positive RTW outcomes [6,26]. Frisk et al. (2023) add another important component including RTW planning and suggestions for policy changes to sick leave to allow greater flexibility, remote work options, and time off for people living with Long COVID due to the episodic nature of symptoms [24]. These research studies found that graduated RTW plans with modified work responsibilities were promising for RTW planning [6,24,26]. Early intervention (less than 6 months) was linked to higher RTW success rates, as shorter times between symptom onset and treatment correlated with improved outcomes and a higher likelihood of successful RTW [6].

Other promising interventions included specialized rehabilitation programs for Long COVID such as using Enhanced External Counter Pulsation (EECP) [25,33]. Sathyamoorthy et al. (2022) found that EECP improved blood flow and reduced cardiac strain, helping alleviate symptoms like persistent fatigue and shortness of breath, which in turn boosted physical endurance and overall well-being, facilitating a more sustainable RTW [33]. The sample size for this study was small (n = 16), thus this approach should be considered exploratory. In addition, a pilot RCT by Uswatte et al. (2024) explored the feasibility of Constraint-Induced Cognitive Therapy (CICT) for people living with Long COVID-related cognitive impairment and IADL dysfunction, demonstrating high completion rates and participation satisfaction [29]. This 36-hour intervention incorporated speed of processing of training, structured IADL practice, and real-world skill transfer, resulting in improvements in brain fog, daily functioning, and psychological well-being [29]. The results are promising and suggest that CICT may facilitate RTW by enhancing cognitive function and independence, thus highlighting its potential as a rehabilitation treatment for Long COVID [29]. Again, the sample size of this pilot study was small (n = 14), thus CICT should be considered exploratory. Lastly, a case report demonstrated improved workability from critical to good using pulse Electromagnetic Field Therapy (EMF) by treating a patient with high magnetic flux density over 5 weeks to manage Long COVID fatigue [41]. This rehabilitation approach is exploratory and may improve RTW results by improving fatigue and overall well-being but true effects on RTW remain unknown (i.e., classified as 'uncertain' effects) [41].

Some interventions were found to have little impact on RTW in people living with Long COVID. Derksen et al. (2023) completed an intervention involving personal pilots and digital rehabilitation, which was unsuccessful in improving RTW outcomes for people living with Long COVID, despite reductions in symptoms [27]. Although personal pilots provided valuable support and helped patients navigate healthcare, their lack of therapeutic training and the reliance on asynchronous digital interventions without a physiotherapist's supervision limited effectiveness [27]. While symptom reduction predicted higher social participation, it did not translate into improved workability, suggesting that broader social factors beyond individual symptom management influence workability [27].

Unsuccessful rehabilitation treatment options often involved aggressive or graded exercise plans without accounting for PEM, which worsened symptoms [38]. Hasenoehrl et al.'s (2023) rehabilitation intervention focused on physical conditioning for individuals with Long COVID to improve endurance, muscular strength, and workability but did not report RTW proportion leaving the intervention to have unknown RTW effects [38]. Although exercise led to significant improvements in physical fitness, psychological outcomes, and reported workability, the individual gains were more pronounced in those with severe fatigue compared to those with milder symptoms [38]. Despite these benefits, the intervention did not significantly enhance RTW overall suggesting that while exercise may lead to improvements in some outcomes, it does not address all the complex components of RTW, especially in individuals with varying levels of fatigue, PEM, and other Long COVID symptoms [38].

The study by Kupferschmitt et al. (2023) showed that a multimodal inpatient rehabilitation program utilizing psychotherapy-based approaches achieved only a marginal 2% improvement in RTW rates, indicating limited effectiveness for RTW recovery among individuals with Long COVID [37]. While patients without signs of PEM benefited from psychological and physical interventions, their psychological burden was lower than that of patients with psychosomatic or psychocardiological conditions, potentially diminishing the impact of the psychotherapy-based methods [37]. Consequently, this approach was regarded as less promising, as the non-curative nature of rehabilitation and the absence of tailored RTW-focused strategies may have contributed to its limited success in facilitating RTW reintegration [37].

Two interventions were deemed of uncertain promise because they did not specifically examine RTW rates after the intervention. However, both studies reported positive outcomes on other work-related measures. Wagner et. al. studied the use of pulsed electromagnetic field therapy and found that the intervention improved self-rated workability from 'critical' (21.5 points) before treatment to 'good' (40 points) after the intervention [41]. As discussed above, Hasenoehrl et. al. studied physical exercise and reported some improvement in self-reported workability in health care workers [38]. Both interventions will need to be evaluated for their impact on actual RTW outcomes.

Guidelines for RTW recommendations emphasize tailored support acknowledging unique needs, symptoms, and personal situations as well as the importance of early intervention, integration of healthcare services, and personalized rehabilitation plans [43]. Proactive involvement of individuals from various areas (clinical, workplace, unions, insurance/compensation, etc.) is important for finding solutions for successful RTW [43]. Individualized, tailored treatment recommendations include starting aerobic exercises at lower intensities with conservative progression and careful symptom monitoring to avoid PEM [48,54]. In addition, it has been recommended that the needs of individual workers be recognized and addressed regarding challenges that may particularly impact RTW, including activity-induced mental and cognitive fatigue, sleep, mood disturbances, and persistent cognitive problems [48,54]. Adequate rest and medical assessment at four weeks post-symptom onset appear crucial for preventing Long COVID symptomology, followed by referrals to specialists and tailored rehabilitation programs as indicated [43]. Treatment should focus on Long COVID symptoms that impact work readiness, with ongoing follow-up, symptom monitoring, and providing self-management resources and contact information for flare-ups [49,52]. Lastly, individualized accessibility recommendations ensure that specific therapies such as pulmonary rehabilitation are accessible to equity-deserving populations, use clear language for ease of interpretability, overcome transportation needs or provide virtual options to support participation in treatment [54].

Workplace accommodations are crucial for people with mild to moderate Long COVID symptoms to stay engaged and safely RTW [49,53]. Recommendations for common accommodations for fatigue include reduced work hours, flexible scheduling, and avoidance of tasks with high cognitive demands [49,53]. Gradual RTW is often necessary due to the unpredictable nature of Long COVID symptoms [44,46,49]. Work task or work environment modifications, guided by healthcare provider-directed restrictions and limitations, can often enable a safe and timely RTW [45,50,53]. Physician and/or clinician guidance is essential to ensure that accommodations preserve functionality and protect against the negative health impacts of worklessness [50,53]. RTW planning meetings have been recommended before gradual RTW to address needs, review workloads, involve union and/or employer representatives and explore modifiable duties and responsibilities [45,48,49]. Some modifications recommended include start and end time flexibility, modifiable hours/days, workload changes, increased frequency of breaks, microbreaks, modified or alternative duties, support mechanisms (i.e. a buddy or work from home options), and equipment adjustments [44 –46,49]. Other recommendations include modifying policies (i.e. sick leave, bullying/harassment, confidentiality around sharing positive testing, etc.), fostering autonomy over scheduling (i.e. remote work, self-management of symptoms, etc.) and workplace goal setting (i.e. modifying targets) [49].

A key workplace accommodation recommendation for people living with Long COVID involves reviewing and changing policies that address disability benefits and employment protection pathways [49,51]. Actions should be taken to adjust policies concerning employment rights and sick pay as well as provide flexibility in leave due to the episodic nature of Long COVID [49,51]. It has been recommended that all countries review and update their wage replacement benefit packages and access to disability benefits for Long COVID [51].

Managers play a significant role in facilitating a successful RTW as they are often the first point of contact for workers considering RTW after Long COVID [44,46,49,50]. RTW for people living with Long COVID requires support and collaboration among multiple parties, including the worker, employer, line manager, and healthcare professionals [43,44,46]. Employers, Human Resources, and supervisors play key roles in providing flexible support, and implementing job modifications and work adjustments from gradual RTW plans to support recovery in the workplace [43,44,46]. Supportive attitudes, active listening, and an accommodating nature are vital for RTW support [44,46]. In addition, recommendations for managers include staying in touch during absences from work, preparing for the worker's return, conducting an RTW discussion, providing support during early RTW days, and implementing modifications [44,46]. Ongoing discussions and regular reviews are essential to address the episodic nature of Long COVID to ensure sustained workability [43,50]. The main objective of discussions should be a gradual and adaptable RTW, alongside support for sustainable approaches to RTW [43,49]. Sustainable employment is beneficial for health from the broader disability perspective as we need work and/or productivity for our overall health and functioning as well as for the global economy [43,49].

For individuals with significant health concerns, such as chest pain or cognitive dysfunction, it is recommended to carry out specific assessments and clearances before resuming strenuous or safety-critical work [43,50]. Physical exercise as an intervention is contraindicated for those experiencing PEM and a fit note should be obtained before starting the program [43,50]. Strengthening exercises should be introduced gradually, and educational modules should be adapted for Long COVID specific challenges and be introduced early [54]. Occupational therapists and psychologists are recommended for Long COVID treatment, in particular for assessing and monitoring RTW readiness [54]. Interventions should always incorporate RTW-specific items in outcome measures as part of the assessment and follow-up to determine if the intervention was successful [50,54].

An important recommendation from clinical practice guidelines related to RTW interventions is to use a holistic, multidisciplinary approach to assess how lives, especially work lives, have been impacted by Long COVID [52]. RTW discussions in programs should involve occupational health services and health professionals to support recovery [43,51,52]. Shared decision-making should guide the discussion with agreement on support and rehabilitation strategies tailored to an individual's needs [50,52]. Creating individualized rehabilitation programs that address all problem areas, including RTW, is crucial [52]. It is recommended that interventions should be tailored to address sleep hygiene, mental health concerns such as depression, stress, and anxiety, assessment and treatment of occupational demands, and supervised physical exercise [48]. Effective RTW planning should focus on overcoming obstacles using a biopsychosocial approach and maintaining adaptability to support people living with Long COVID throughout their recovery [43,49]. This includes setting realistic expectations, focusing on what can be achieved, and addressing both physical and psychological functioning [43]. At this time, guidelines state that initial examinations or assessments prior to interventions should include the one-minute sit-to-stand test and three-minute active stand test to screen for orthostatic intolerance and PEM [48].

Aggressive exercise such as resistance exercise training or graded activity, is often counterproductive for individuals with Long COVID due to the high prevalence of PEM and the episodic nature of fluctuating symptoms like fatigue, autonomic dysfunction, and cognitive impairments [2,4,13,16,38]. Unlike traditional rehabilitation where exercise is used to improve functional abilities and work readiness, for individuals with Long COVID experiencing PEM, excessive physical exertion can exacerbate symptoms leading to prolonged recovery setbacks [2,13,16]. Graded exercise for those with PEM is currently contraindicated and studies indicate that interventions ignoring PEM risk worsening fatigue and other symptoms, thus reducing the effectiveness of rehabilitation and potentially delaying RTW [2,13,16]. Therefore, baseline measurements and monitoring symptoms must be a component of treatment where physical conditioning is involved [31]. Overall, the current recommendation is a conservative, individualized approach to physical activity that prioritizes pacing and symptom monitoring to ensure safety and RTW support for individuals living with Long COVID.

Unsupervised or self-directed rehabilitation programs via an app for Long COVID recovery may be insufficient, as they often lack the personalized oversight necessary to manage complex, fluctuating symptoms effectively. Less effective treatment approaches, such as self-directed via app programs, often overlooked crucial elements such as pacing, orthostatic intolerance and PEM hindering RTW and/or led to no changes in global fatigue [27]. For those with symptoms such as fatigue, brain fog, and autonomic dysfunction, supervision and modifications are frequently needed, which digital platforms alone often cannot support [2,27,38,42]. As such, programs that do not provide proper training for people living with Long COVID or rely on digital interventions without supervision were found to be less effective [27]. These treatment programs also have the potential to worsen PEM and impact overall recovery for individuals with Long COVID, potentially delaying RTW [27,38]. Without direct feedback from clinicians, patients may overexert themselves or miss subtle warning signs of PEM, risking flare-up hindering overall recovery and delaying RTW [13,27]. This indicates the need for a more comprehensive approach that is supervised, multidisciplinary, and individualized, targeting the individual's personal and contextual needs. Virtual rehabilitation treatment with mindfulness, and physical and sensory exercises but no clinician supervision was found to lead to symptom reduction but no RTW, highlighting the need for clinician support as stated in other sources [6,27,38]. Studies show that in-person, supervised care from clinicians is vital to ensure effective and safe pacing, modifications to programs, and comprehensive support necessary for sustainable RTW [27,56].

Although Long COVID rehabilitation can address physical and psychological symptoms, programs addressing every symptom with multiple outcome measures may fall short in RTW preparation and managing fatigue [35]. Using too many outcome measures or maximal testing with a performance-based assessment of workability may overwhelm patients and clinicians, detracting from effective rehabilitation. Due to a lack of treatment options for the over 200 possible symptoms of Long COVID, clinicians may feel pressured to document all problem areas. With too many measures, the attention on meaningful progress or change can be diluted, making it difficult to identify which interventions truly support Long COVID recovery for RTW. Individuals with Long COVID often struggle with global fatigue and PEM, which may add cognitive and physical strain, further complicating the recovery process [13,16]. They often require pacing and energy conservation strategies to manage symptoms; thus, intensive programs with multiple outcome measures can be additionally fatiguing, exacerbating PEM or worsening symptoms for these individuals [31]. There is a need to streamline outcome metrics to focus on core areas such as functional capacity, symptom management, and RTW readiness to allow clarity for more actionable insights, helping both clients and clinicians with targeted support that aligns with the unique and variable needs of each person with Long COVID.